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SE CIMS - 122
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Date
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MM
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DD
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YYYY
From (Teacher's Name)
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Subject
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Student's Name
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Date of Birth
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MM
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DD
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YYYY
District of Residence
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District of Attendance
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Grade Level
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Date of Referral
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MM
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DD
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YYYY
Date of Last IEP
MM
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DD
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YYYY
Date of Last ETR
MM
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DD
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YYYY
Date of Initial Placement
MM
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DD
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YYYY
Suspected Disability
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Primary Disability
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Related Service
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Reason for CIMS-122
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Notes/Comments (added info)
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